Minimally Invasive Treatment of Spinal Deformity in a High-risk Patient
The patient is a 63-year-old male. He is active and avidly practices martial arts. He has significant pain in his lower back, as well as bilateral lower extremity pain in no particular radicular distribution. Pain has limited his martial arts practice and general activities of daily living. He is unable to walk for more than half-a-block before the pain forces him to sit down.
- Two years of conservative pain management has not provided pain relief.
- Cardiology evaluation states that the patient cannot safely be off warfarin for more than 3 days.
- Mechanical aortic valve replacement on warfarin with a goal of INR 2.5-3.
- Height: 5'10"
- Weight: 170 pounds
- BMI: 24
- Vital signs within normal limits
- Alert and oriented; well-developed, well-nourished
- Moves all extremities with 5/5 strength symmetrically
- Deep tendon reflexes are 1+ throughout
- Antalgic, stooped gait
- Adult degenerative scoliosis with the apex of his scoliotic curve at L2/L3 on lateral bending radiographs.
- Sagittal vertical axis (SVA) 3 cm, pelvic incidence (PI) 55°, lumbar lordosis (LL) 43°, pelvic tilt (PT) 26°, and coronal Cobb angle 24°.
- No pelvic obliquity was present.
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The significant risks of surgery related to cardiac function were explained to the patient. However, because of significant (severe) pain he decided to proceed with surgery.
He was admitted 48 hours prior to surgery and warfarin was held. He was placed on a heparin drip that was discontinued the evening before surgery. Serial INRs were checked until normalized.
He was taken to the operating room for a L1-L5 extreme lateral interbody fusion only, with no posterior fixation planned unless the patient decompensated in follow up imaging.
Post-operative Images at 18-month Follow-up
- Post-operative SVA - 2.3 cm, PI = 55°, LL = 48°, PT = 24°, and coronal Cobb angle = 17°
At one year post-surgery, the patient is doing well. He has significant improvement in his back and leg pain. He required no further surgery, including posterior fixation/fusion.
The authors present a commonly encountered pathology in an active gentleman with cardiac comorbidity. Traditional anterior/posterior fixation of this deformity would prove challenging given the limited duration of holding anticoagulation and high likelihood of post-operative bleeding.
The LLIF procedure is a valuable tool in the treatment of adult degenerative scoliosis and affords excellent coronal plane deformity correction, as well as some sagittal plane correction as this case illustrates. The authors obtained a modest correction of the deformity with marked clinical benefit.
While stand-alone LLIF has well documented success1,2, I prefer to use an implant with intrinsic plating, which provides some, albeit minimal, additional stability with a minimal increase in operative time. The stand-alone (or intrinsically plated) construct has tremendous stability in lateral bending but is much less stable in flexion, extension and torsional rotation.
With a patient who is active, practicing martial arts, I would typically back up a construct like this with percutaneous screws in the acute phase. In my experience, when a stand-alone construct subsides, the revision is far more cumbersome with a poorer outcome than the added burden of percutaneous screws early on.
1. Lykissas MG, Aichmair A, Hughes AP, Sama AA, Lebl DR, Taher F, et al. Nerve injury after lateral lumbar interbody fusion: a review of 919 treated levels with identification of risk factors. Spine J. September 9, 2013. (10.1016/j.spinee.2013.06.066)
2. Isaacs RE, Hyde J, Goodrich JA, Rodgers WB, Phillips FM. A prospective, nonrandomized, multicenter evaluation of extreme lateral interbody fusion for the treatment of adult degenerative scoliosis: perioperative outcomes and complications. Spine. 2010 Dec 15;35(26 Suppl):S322-S330.
We thank Dr. Highsmith for his thoughtful evaluation of the presented case. We agree that additional stabilization of the posterior column has an enormous benefit (eg, protects indirect decompression, provides coronal/sagittal correction, subsidence prevention, etc.) and is, in fact, often our practice. However, we evaluate each patient on an individual basis and concluded that the risk to benefit ratio in this case weighed in favor of a standalone construct.
This would decrease time under anesthesia, allow for an anti-coagulant to be restarted sooner, and reduce the risk of post-operative hematoma. In addition, it has been shown that lateral, or intrinsic, plating does not protect from subsidence, and may, in actuality, potentially increase the risk of lumbar plexus injury by increasing retractor aperture and time. The addition of fixation points (screws) above and below the implants can actually promote the occurrence of subsidence and vertebral coronal fractures.1, 2 The lateral plate construct does not offer additional coronal or sagittal correction in scoliosis cases, and does not protect correction obtained from lateral cages, since the plate only offers fixation of one motion segment at a time, and only in one plane, as mentioned previously.
The available armamentarium in the treatment of spinal pathology has grown rapidly over the last decade, allowing for many variations in the treatment of cases such as this. We only offer our rationale in this patient's care.
1. Le TV, Baaj AA, Dakwar E, Burkett CJ, Murray G, Smith DA, Uribe JS. Subsidence of polyetheretherketone intervertebral cages in minimally invasive lateral retroperitoneal transpsoas lumbar interbody fusion. Spine. 2012;37:1268-1273.
2. Le TV, Smith DA, Greenberg MS, Dakwar E, Baaj AA, Uribe JS. Complications of lateral plating in the minimally invasive lateral transpsoas approach. J Neurosurg Spine. 2012;16:302-307.